Question

Difficulty: HardSurgical and Procedural Interventions

An otherwise healthy 45-year-old woman arrives at the acute care clinic with sudden-onset, excruciating periumbilical pain and unremitting vomiting. Over the past 14 hours, her emesis has transitioned from clear fluid to bilious material. She reports no passage of flatus or stool since the symptoms commenced. Her medical and surgical histories are unremarkable. On initial triage, her temperature is 38.0°C (100.4°F), heart rate is 118/min, blood pressure is 108/65 mm Hg, and respiratory rate is 22/min. Physical examination demonstrates an asymmetrically distended abdomen featuring a prominent, tympanitic mass that spans from the right lower quadrant toward the epigastrium. Auscultation reveals high-pitched, tinkling bowel sounds. Initial laboratory analysis shows a leukocyte count of 14,200/mm³ and a serum lactate concentration of 3.1 mmol/L (Normal: 0.5-2.2 mmol/L). An urgent computed tomography scan of the abdomen and pelvis shows a massively dilated cecum flipped into the upper abdomen, accompanied by a twisting of the mesenteric vessels and a fully collapsed distal colon. Which of the following is the most appropriate next step in management?

  1. Urgent exploratory laparotomy and bowel resectionAnswer
  2. B
    Endoscopic decompression via flexible sigmoidoscopy
  3. C
    Intravenous administration of neostigmine
  4. D
    Fluoroscopic enema using water-soluble contrast
  5. E
    Nasogastric tube decompression and serial observation

Answer

Urgent exploratory laparotomy and bowel resection
The correct answer involves immediately proceeding to the operating room. The patient's clinical presentation (fever, tachycardia, severe pain) and laboratory findings (leukocytosis, elevated lactate) are highly concerning for bowel ischemia secondary to a strangulated mechanical obstruction. The CT scan definitively confirms a cecal volvulus. Because the cecum twists on its mesentery, the vascular supply is compromised early. Endoscopic detorsion is highly unsuccessful and dangerous for cecal volvulus (unlike sigmoid volvulus). Therefore, the standard of care is urgent surgical exploration, typically involving a right hemicolectomy or ileocecectomy.

Step-by-Step Solution

1
Analyze the patient's clinical presentation and vitals.
The patient presents with signs of an acute abdomen, including severe pain, bilious vomiting, obstipation, fever, tachycardia, and an elevated lactate level of 3.1 mmol/L.
These findings indicate a severe mechanical bowel obstruction complicated by impending or actual bowel ischemia (strangulation).
2
Evaluate the imaging findings provided in the stem.
The CT scan shows a massively dilated cecum with a twisted mesentery ('whirl sign') extending into the upper abdomen.
This radiologic pattern is definitively diagnostic of a cecal volvulus.
3
Determine the appropriate procedural intervention based on the diagnosis and patient stability.
Unlike sigmoid volvulus, which can often be managed endoscopically, cecal volvulus requires surgical management (such as a right hemicolectomy or ileocecectomy). The presence of ischemic signs mandates an immediate operative approach.
Endoscopy is largely ineffective and hazardous for cecal volvulus, and medical management is contraindicated in mechanical strangulation.

Key Concept

Cecal volvulus inherently carries a high risk of bowel ischemia and perforation; therefore, the definitive and most appropriate management is emergent surgical exploration and bowel resection, especially when systemic signs of ischemia (e.g., elevated lactate, leukocytosis) are present.
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